DSTU2 FHIR Release 3 (STU)

This page is part of the FHIR Specification (v1.0.2: DSTU (v3.0.2: STU 2). 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R3 R2 R3 R2

7.5 13.3 Resource EligibilityResponse - Content

This resource is marked as a draft .
Financial Management Work Group Maturity Level : 0 2   Trial Use Compartments : Not linked to any defined compartments Practitioner

This resource provides eligibility and plan details from the processing of an Eligibility resource.

7.5.1 13.3.1 Scope and Usage

This resource has not yet undergone proper review by FM. At this time, it is to be considered as a draft. The EligibilityResponse resource provides eligibility and plan details from the processing of an Eligibility EligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy details.

Todo

7.5.2 13.3.2 Resource Content

Structure

Σ Σ Claim Σ Σ Resource version Original version Creation date Insurer 0..1 Reference Responsible practitioner Responsible organization
Name Flags Card. Type Description & Constraints doco
. . EligibilityResponse DomainResource EligibilityResponse resource
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier
. . request . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
... created 0..1 dateTime Creation date
... requestProvider 0..1 Reference ( Practitioner ) Responsible practitioner
... requestOrganization 0..1 Reference ( Organization ) Responsible organization
... request 0..1 Reference ( EligibilityRequest ) Eligibility reference
. . . outcome 0..1 code CodeableConcept complete | error | partial
RemittanceOutcome ( Required )
. . . disposition 0..1 string Disposition Message
. . ruleset . insurer Σ 0..1 Reference ( Organization ) Insurer issuing the coverage
... inforce 0..1 Coding boolean Coverage inforce indicator
... insurance 0..* BackboneElement Details by insurance coverage
Ruleset Codes
. . . . coverage 0..1 Reference ( Example Coverage ) Updated Coverage details
. . originalRuleset . . contract Σ 0..1 Reference ( Contract ) Contract details
.... benefitBalance 0..* BackboneElement Benefits by Category
..... category 1..1 CodeableConcept Type of services covered
Benefit Category Codes ( Example )
..... subCategory 0..1 Coding CodeableConcept Detailed services covered within the type
Ruleset Benefit SubCategory Codes ( Example )
. . created . . . excluded Σ 0..1 boolean Excluded from the plan
..... name 0..1 dateTime string Short name for the benefit
. . organization . . . description Σ 0..1 string Description of the benefit or services covered
..... network 0..1 Reference CodeableConcept In or out of network
Network Type Codes ( Organization Example )
. . . . . unit 0..1 CodeableConcept Individual or family
Unit Type Codes ( Example )
. . requestProvider . . . term Σ 0..1 CodeableConcept Annual or lifetime
Benefit Term Codes ( Example )
. . . . . financial 0..* BackboneElement Benefit Summary
...... type 1..1 CodeableConcept Deductable, visits, benefit amount
Benefit Type Codes ( Practitioner Example )
. . . . . . allowed[x] 0..1 Benefits allowed
. . requestOrganization . . . . . allowedUnsignedInt unsignedInt
. . . . . . . allowedString string Σ
. . . . . . . allowedMoney Money
...... used[x] 0..1 Reference Benefits used
....... usedUnsignedInt unsignedInt
....... usedMoney Money
... form 0..1 CodeableConcept Printed Form Identifier
Form Codes ( Organization Example )
. . . error 0..* BackboneElement Processing errors
.... code 1..1 CodeableConcept Error code detailing processing issues
Adjudication Error Codes ( Example )

doco Documentation for this format

UML Diagram ( Legend )

EligibilityResponse ( DomainResource ) The Response business identifier identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status ! The date when the enclosed suite of services were performed or completed created : dateTime [0..1] The practitioner who is responsible for the services rendered to the patient requestProvider : Reference [0..1] Practitioner The organization which is responsible for the services rendered to the patient requestOrganization : Reference [0..1] Organization Original request resource reference request : Reference [0..1] « EligibilityRequest » Transaction status: error, complete outcome : code CodeableConcept [0..1] « The outcome of the processing. (Strength=Required) RemittanceOutcome ! » A description of the status of the adjudication disposition : string [0..1] The version of Insurer who produced this adjudicated response insurer : Reference [0..1] Organization Flag indicating if the style coverage provided is inforce currently if no service date(s) specified or for the whole duration of resource contents. This should be mapped to the allowable profiles for this and supporting resources service dates ruleset inforce : Coding boolean [0..1] « The static and dynamic model form to which contents conform, which may be business version or standard/version. used for printing the content form : CodeableConcept [0..1] The forms codes. (Strength=Example) Ruleset Form ?? » Insurance The style (standard) and version A suite of updated or additional Coverages from the original material which was converted into this resource Insurer originalRuleset coverage : Coding Reference [0..1] « Coverage The static and dynamic model to which contents conform, contract resource which may be business version or standard/version. provide more detailed information contract : Reference [0..1] Contract Benefits Dental, Vision, Medical, Pharmacy, Rehab etc category : CodeableConcept [1..1] Benefit categories such as: oral, medical, vision etc. (Strength=Example) Ruleset Benefit Category ?? » The date when Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? True if the enclosed suite indicated class of services were performed service is excluded from the plan, missing or completed False indicated the service is included in the coverage created excluded : dateTime boolean [0..1] The Insurer who produced this adjudicated response A short name or tag for the benefit, for example MED01, or DENT2 organization name : Reference string [0..1] « Organization » The practitioner who is responsible for A richer description of the services rendered benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services' description : string [0..1] Network designation network : CodeableConcept [0..1] Code to the patient classify in or out of network services (Strength=Example) requestProvider Network Type ?? Unit designation: individual or family unit : Reference CodeableConcept [0..1] « Practitioner Unit covered/serviced - individual or family (Strength=Example) Unit Type » ?? The organization which is responsible for the services rendered to term or period of the patient values such as 'maximum lifetime benefit' or 'maximum annual vistis' requestOrganization term : Reference CodeableConcept [0..1] « Organization Coverage unit - annual, lifetime (Strength=Example) Benefit Term » ?? Benefit Deductable, visits, benefit amount type : CodeableConcept [1..1] Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? Benefits allowed allowed[x] : Type [0..1] unsignedInt | string | Money Benefits used used[x] : Type [0..1] unsignedInt | Money Errors An error code,from a specified code system, which details why the eligibility check could not be performed code : CodeableConcept [1..1] The error codes for adjudication processing. (Strength=Example) Adjudication Error ?? Benefits Used to date financial [0..*] Benefits and optionally current balances by Category benefitBalance [0..*] The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer insurance [0..*] Mutually exclusive with Services Provided (Item) error [0..*]

XML Template 

<

<EligibilityResponse xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <
 <
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>

 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(EligibilityRequest) Eligibility reference --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 0..1 Reference(Organization) Insurer issuing the coverage --></insurer>
 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
 <insurance>  <!-- 0..* Details by insurance coverage -->
  <coverage><!-- 0..1 Reference(Coverage) Updated Coverage details --></coverage>
  <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
  <benefitBalance>  <!-- 0..* Benefits by Category -->
   <category><!-- 1..1 CodeableConcept Type of services covered --></category>
   <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></subCategory>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <financial>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
   </financial>
  </benefitBalance>
 </insurance>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>

</EligibilityResponse>

JSON Template 

{
  "resourceType" : "",

{doco
  "resourceType" : "EligibilityResponse",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "created" : "<dateTime>", // Creation date
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(EligibilityRequest) }, // Eligibility reference
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer issuing the coverage
  "inforce" : <boolean>, // Coverage inforce indicator
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "benefitBalance" : [{ // Benefits by Category
      "category" : { CodeableConcept }, // R!  Type of services covered
      "subCategory" : { CodeableConcept }, // Detailed services covered within the type
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "financial" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount
        // allowed[x]: Benefits allowed. One of these 3:

        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 2:

        "usedUnsignedInt" : "<unsignedInt>"
        "usedMoney" : { Money }
      }]
    }]
  }],
  "form" : { CodeableConcept }, // Printed Form Identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]

}

Turtle Template 


@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:EligibilityResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:EligibilityResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:EligibilityResponse.request [ Reference(EligibilityRequest) ]; # 0..1 Eligibility reference
  fhir:EligibilityResponse.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer issuing the coverage
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce indicator
  fhir:EligibilityResponse.insurance [ # 0..* Details by insurance coverage
    fhir:EligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 0..1 Updated Coverage details
    fhir:EligibilityResponse.insurance.contract [ Reference(Contract) ]; # 0..1 Contract details
    fhir:EligibilityResponse.insurance.benefitBalance [ # 0..* Benefits by Category
      fhir:EligibilityResponse.insurance.benefitBalance.category [ CodeableConcept ]; # 1..1 Type of services covered
      fhir:EligibilityResponse.insurance.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
      fhir:EligibilityResponse.insurance.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:EligibilityResponse.insurance.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
      fhir:EligibilityResponse.insurance.benefitBalance.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:EligibilityResponse.insurance.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:EligibilityResponse.insurance.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:EligibilityResponse.insurance.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:EligibilityResponse.insurance.benefitBalance.financial [ # 0..* Benefit Summary
        fhir:EligibilityResponse.insurance.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Deductable, visits, benefit amount
        # EligibilityResponse.insurance.benefitBalance.financial.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedString [ string ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedMoney [ Money ]
        # EligibilityResponse.insurance.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedMoney [ Money ]
      ], ...;
    ], ...;
  ], ...;
  fhir:EligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:EligibilityResponse.error [ # 0..* Processing errors
    fhir:EligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since DSTU2

EligibilityResponse
EligibilityResponse.status
  • Added Element
EligibilityResponse.outcome
  • Type changed from code to CodeableConcept
EligibilityResponse.insurer
  • Added Element
EligibilityResponse.inforce
  • Added Element
EligibilityResponse.insurance
  • Added Element
EligibilityResponse.insurance.coverage
  • Added Element
EligibilityResponse.insurance.contract
  • Added Element
EligibilityResponse.insurance.benefitBalance
  • Added Element
EligibilityResponse.insurance.benefitBalance.category
  • Added Element
EligibilityResponse.insurance.benefitBalance.subCategory
  • Added Element
EligibilityResponse.insurance.benefitBalance.excluded
  • Added Element
EligibilityResponse.insurance.benefitBalance.name
  • Added Element
EligibilityResponse.insurance.benefitBalance.description
  • Added Element
EligibilityResponse.insurance.benefitBalance.network
  • Added Element
EligibilityResponse.insurance.benefitBalance.unit
  • Added Element
EligibilityResponse.insurance.benefitBalance.term
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.type
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.allowed[x]
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.used[x]
  • Added Element
EligibilityResponse.form
  • Added Element
EligibilityResponse.error
  • Added Element
EligibilityResponse.error.code
  • Added Element
EligibilityResponse.ruleset
  • deleted
EligibilityResponse.originalRuleset
  • deleted
EligibilityResponse.organization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

Structure

Σ Σ Claim Σ Σ Resource version Original version Creation date Insurer 0..1 Reference Responsible practitioner Responsible organization
Name Flags Card. Type Description & Constraints doco
. . EligibilityResponse DomainResource EligibilityResponse resource
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier
. . request . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
... created 0..1 dateTime Creation date
... requestProvider 0..1 Reference ( Practitioner ) Responsible practitioner
... requestOrganization 0..1 Reference ( Organization ) Responsible organization
... request 0..1 Reference ( EligibilityRequest ) Eligibility reference
. . . outcome 0..1 code CodeableConcept complete | error | partial
RemittanceOutcome ( Required )
. . . disposition 0..1 string Disposition Message
. . ruleset . insurer Σ 0..1 Reference ( Organization ) Insurer issuing the coverage
... inforce 0..1 Coding boolean Coverage inforce indicator
... insurance 0..* BackboneElement Details by insurance coverage
Ruleset Codes
. . . . coverage 0..1 Reference ( Example Coverage ) Updated Coverage details
. . originalRuleset . . contract Σ 0..1 Reference ( Contract ) Contract details
.... benefitBalance 0..* BackboneElement Benefits by Category
..... category 1..1 CodeableConcept Type of services covered
Benefit Category Codes ( Example )
..... subCategory 0..1 Coding CodeableConcept Detailed services covered within the type
Ruleset Benefit SubCategory Codes ( Example )
. . created . . . excluded Σ 0..1 boolean Excluded from the plan
..... name 0..1 dateTime string Short name for the benefit
. . organization . . . description Σ 0..1 string Description of the benefit or services covered
..... network 0..1 Reference CodeableConcept In or out of network
Network Type Codes ( Organization Example )
. . . . . unit 0..1 CodeableConcept Individual or family
Unit Type Codes ( Example )
. . requestProvider . . . term Σ 0..1 CodeableConcept Annual or lifetime
Benefit Term Codes ( Example )
. . . . . financial 0..* BackboneElement Benefit Summary
...... type 1..1 CodeableConcept Deductable, visits, benefit amount
Benefit Type Codes ( Practitioner Example )
. . . . . . allowed[x] 0..1 Benefits allowed
. . requestOrganization . . . . . allowedUnsignedInt unsignedInt
. . . . . . . allowedString string Σ
. . . . . . . allowedMoney Money
...... used[x] 0..1 Reference Benefits used
....... usedUnsignedInt unsignedInt
....... usedMoney Money
... form 0..1 CodeableConcept Printed Form Identifier
Form Codes ( Organization Example )
. . . error 0..* BackboneElement Processing errors
.... code 1..1 CodeableConcept Error code detailing processing issues
Adjudication Error Codes ( Example )

doco Documentation for this format

UML Diagram ( Legend )

EligibilityResponse ( DomainResource ) The Response business identifier identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status ! The date when the enclosed suite of services were performed or completed created : dateTime [0..1] The practitioner who is responsible for the services rendered to the patient requestProvider : Reference [0..1] Practitioner The organization which is responsible for the services rendered to the patient requestOrganization : Reference [0..1] Organization Original request resource reference request : Reference [0..1] « EligibilityRequest » Transaction status: error, complete outcome : code CodeableConcept [0..1] « The outcome of the processing. (Strength=Required) RemittanceOutcome ! » A description of the status of the adjudication disposition : string [0..1] The version of Insurer who produced this adjudicated response insurer : Reference [0..1] Organization Flag indicating if the style coverage provided is inforce currently if no service date(s) specified or for the whole duration of resource contents. This should be mapped to the allowable profiles for this and supporting resources service dates ruleset inforce : Coding boolean [0..1] « The static and dynamic model form to which contents conform, which may be business version or standard/version. used for printing the content form : CodeableConcept [0..1] The forms codes. (Strength=Example) Ruleset Form ?? » Insurance The style (standard) and version A suite of updated or additional Coverages from the original material which was converted into this resource Insurer originalRuleset coverage : Coding Reference [0..1] « Coverage The static and dynamic model to which contents conform, contract resource which may be business version or standard/version. provide more detailed information contract : Reference [0..1] Contract Benefits Dental, Vision, Medical, Pharmacy, Rehab etc category : CodeableConcept [1..1] Benefit categories such as: oral, medical, vision etc. (Strength=Example) Ruleset Benefit Category ?? » The date when Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? True if the enclosed suite indicated class of services were performed service is excluded from the plan, missing or completed False indicated the service is included in the coverage created excluded : dateTime boolean [0..1] The Insurer who produced this adjudicated response A short name or tag for the benefit, for example MED01, or DENT2 organization name : Reference string [0..1] « Organization » The practitioner who is responsible for A richer description of the services rendered benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services' description : string [0..1] Network designation network : CodeableConcept [0..1] Code to the patient classify in or out of network services (Strength=Example) requestProvider Network Type ?? Unit designation: individual or family unit : Reference CodeableConcept [0..1] « Practitioner Unit covered/serviced - individual or family (Strength=Example) Unit Type » ?? The organization which is responsible for the services rendered to term or period of the patient values such as 'maximum lifetime benefit' or 'maximum annual vistis' requestOrganization term : Reference CodeableConcept [0..1] « Organization Coverage unit - annual, lifetime (Strength=Example) Benefit Term » ?? Benefit Deductable, visits, benefit amount type : CodeableConcept [1..1] Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? Benefits allowed allowed[x] : Type [0..1] unsignedInt | string | Money Benefits used used[x] : Type [0..1] unsignedInt | Money Errors An error code,from a specified code system, which details why the eligibility check could not be performed code : CodeableConcept [1..1] The error codes for adjudication processing. (Strength=Example) Adjudication Error ?? Benefits Used to date financial [0..*] Benefits and optionally current balances by Category benefitBalance [0..*] The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer insurance [0..*] Mutually exclusive with Services Provided (Item) error [0..*]

XML Template 

<

<EligibilityResponse xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <
 <
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>

 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(EligibilityRequest) Eligibility reference --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 0..1 Reference(Organization) Insurer issuing the coverage --></insurer>
 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
 <insurance>  <!-- 0..* Details by insurance coverage -->
  <coverage><!-- 0..1 Reference(Coverage) Updated Coverage details --></coverage>
  <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
  <benefitBalance>  <!-- 0..* Benefits by Category -->
   <category><!-- 1..1 CodeableConcept Type of services covered --></category>
   <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></subCategory>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <financial>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
   </financial>
  </benefitBalance>
 </insurance>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>

</EligibilityResponse>

JSON Template 

{
  "resourceType" : "",

{doco
  "resourceType" : "EligibilityResponse",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "created" : "<dateTime>", // Creation date
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(EligibilityRequest) }, // Eligibility reference
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer issuing the coverage
  "inforce" : <boolean>, // Coverage inforce indicator
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "benefitBalance" : [{ // Benefits by Category
      "category" : { CodeableConcept }, // R!  Type of services covered
      "subCategory" : { CodeableConcept }, // Detailed services covered within the type
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "financial" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount
        // allowed[x]: Benefits allowed. One of these 3:

        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 2:

        "usedUnsignedInt" : "<unsignedInt>"
        "usedMoney" : { Money }
      }]
    }]
  }],
  "form" : { CodeableConcept }, // Printed Form Identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]

}

Turtle Template 


@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:EligibilityResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:EligibilityResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:EligibilityResponse.request [ Reference(EligibilityRequest) ]; # 0..1 Eligibility reference
  fhir:EligibilityResponse.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer issuing the coverage
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce indicator
  fhir:EligibilityResponse.insurance [ # 0..* Details by insurance coverage
    fhir:EligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 0..1 Updated Coverage details
    fhir:EligibilityResponse.insurance.contract [ Reference(Contract) ]; # 0..1 Contract details
    fhir:EligibilityResponse.insurance.benefitBalance [ # 0..* Benefits by Category
      fhir:EligibilityResponse.insurance.benefitBalance.category [ CodeableConcept ]; # 1..1 Type of services covered
      fhir:EligibilityResponse.insurance.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
      fhir:EligibilityResponse.insurance.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:EligibilityResponse.insurance.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
      fhir:EligibilityResponse.insurance.benefitBalance.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:EligibilityResponse.insurance.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:EligibilityResponse.insurance.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:EligibilityResponse.insurance.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:EligibilityResponse.insurance.benefitBalance.financial [ # 0..* Benefit Summary
        fhir:EligibilityResponse.insurance.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Deductable, visits, benefit amount
        # EligibilityResponse.insurance.benefitBalance.financial.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedString [ string ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedMoney [ Money ]
        # EligibilityResponse.insurance.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedMoney [ Money ]
      ], ...;
    ], ...;
  ], ...;
  fhir:EligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:EligibilityResponse.error [ # 0..* Processing errors
    fhir:EligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

  Changes since DSTU2

EligibilityResponse
EligibilityResponse.status
  • Added Element
EligibilityResponse.outcome
  • Type changed from code to CodeableConcept
EligibilityResponse.insurer
  • Added Element
EligibilityResponse.inforce
  • Added Element
EligibilityResponse.insurance
  • Added Element
EligibilityResponse.insurance.coverage
  • Added Element
EligibilityResponse.insurance.contract
  • Added Element
EligibilityResponse.insurance.benefitBalance
  • Added Element
EligibilityResponse.insurance.benefitBalance.category
  • Added Element
EligibilityResponse.insurance.benefitBalance.subCategory
  • Added Element
EligibilityResponse.insurance.benefitBalance.excluded
  • Added Element
EligibilityResponse.insurance.benefitBalance.name
  • Added Element
EligibilityResponse.insurance.benefitBalance.description
  • Added Element
EligibilityResponse.insurance.benefitBalance.network
  • Added Element
EligibilityResponse.insurance.benefitBalance.unit
  • Added Element
EligibilityResponse.insurance.benefitBalance.term
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.type
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.allowed[x]
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.used[x]
  • Added Element
EligibilityResponse.form
  • Added Element
EligibilityResponse.error
  • Added Element
EligibilityResponse.error.code
  • Added Element
EligibilityResponse.ruleset
  • deleted
EligibilityResponse.originalRuleset
  • deleted
EligibilityResponse.organization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

 

Alternate definitions: Schema / Schematron , Resource Profile Master Definition ( XML , JSON ), Questionnaire XML Schema / Schematron (for ) + JSON Schema , ShEx (for Turtle )

7.5.2.1 13.3.2.1 Terminology Bindings

EligibilityResponse.ruleset EligibilityResponse.originalRuleset
Path Definition Type Reference
EligibilityResponse.status A code specifying the state of the resource instance. Required Financial Resource Status Codes
EligibilityResponse.outcome The outcome of the processing. Required RemittanceOutcome
EligibilityResponse.insurance.benefitBalance.category The static and dynamic model Benefit categories such as: oral, medical, vision etc. Example Benefit Category Codes
EligibilityResponse.insurance.benefitBalance.subCategory Benefit subcategories such as: oral-basic, major, glasses Example Benefit SubCategory Codes
EligibilityResponse.insurance.benefitBalance.network Code to which contents conform, which may be business version classify in or standard/version. out of network services Example Ruleset Network Type Codes
EligibilityResponse.insurance.benefitBalance.unit Unit covered/serviced - individual or family Example Unit Type Codes
EligibilityResponse.insurance.benefitBalance.term Coverage unit - annual, lifetime Example Benefit Term Codes
EligibilityResponse.insurance.benefitBalance.financial.type Deductable, visits, co-pay, etc. Example Benefit Type Codes
EligibilityResponse.form The forms codes. Example Form Codes
EligibilityResponse.error.code The error codes for adjudication processing. Example Adjudication Error Codes

7.5.3 13.3.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Paths Expression In Common
created date The creation date EligibilityResponse.created
disposition string The contents of the disposition message EligibilityResponse.disposition
identifier token The business identifier of the Explanation of Benefit EligibilityResponse.identifier
insurer reference The organization which generated this resource EligibilityResponse.insurer
( Organization )
outcome token The processing outcome EligibilityResponse.outcome
request reference The EligibilityRequest reference EligibilityResponse.request
( EligibilityRequest )
request-organization reference The EligibilityRequest organization EligibilityResponse.requestOrganization
( Organization )
request-provider reference The EligibilityRequest provider EligibilityResponse.requestProvider
( Practitioner )